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i am a psr trained surgeon,with board certification (abps) and was quite intrigued by all this fuss.the reality is that you can't promote one type of surgery as a cure all.there has been very grave outcomes seen as a result of poor mis surgery.
however,having said that we can not be blind to the fact that all orthopedic surgery including the foot and ankle,is moving towards minimal incision techniques.if you look at the academy of ambulatory foot surgeons,they may be dismissed by our profession.but they have a huge following world wide (europe,asia,latin america) among orthopedic surgeons,i might add.they have been able to make their case to these orthopods that this is where foot surgery is headed.even the great lowel scot weil,d.p.m. had to admit that may be he had not fully researched into this form of surgery before previously criticizing it(paraphrasing).he said this after ecountering it while on a visit to europe.
i don't practice it,because i haven't been trained in it.however,i will tell you that i have encountered their patients and they are happy ones,who would never consider conventional surgery.in terms of poor results,i believe their rate of failure is no different than those of bad "open" surgeons.
if we as a profession don't invest the resources and time to standardize these techniques.i guarantee you orthopods and even plastic surgeons will dominate this type of surgery in the future.
MIS should only be performed by those surgeons with the training to perform them. Like any procedure performed by an inexperienced doctor the results can be horrendous. The schools have removed the texts on this subject and thus these revolutionary techniques are not taught in the schools. The professors in the colleges don't have the training or experience to teach these techniques and for obvious reasons don't want them introduced. Nobody wants to be retrained to learn anything new. Traditional surgeons should not be threatened by MIS surgeons, but it seems most are. All MIS surgeons were trained in traditional surgery, but very, very few traditional surgeons have any training from qualified MIS surgeons. Patients are now demanding minimally invasive procedures in every field of surgery. Patients do not want any long scars, stitches, wires, pins, screws, staples, casts, or surgical shoes. Patients want foot surgery performed in the doctor's office, just as they prefer dental surgery. Patients don't want to have to obtain medical clearance or undergo unnecessary blood tests, EKG's, Chest x-rays, potentially harmful anesthesia or any prolonged post operative physical therapy sessions. These techniques are now over 40 years old and if they didn't work they would have dissappeared years ago. MIS doctors advise their patients they will not have any "home-depot" hardware in their feet, can bathe or shower the day after surgery, drive in a day or two, and wear their own shoes almost immediately. This is modern podiatry.
i agree with dr. wexler with regards to acceptance by patients of mis.whether we admit it or not the types of procedures we offer to our patients are very much market driven.if patients (consumers) reject a certain procedure it will be phased out in time,regardless of results.on the other hand,procedures which offer patients reproducible good results,and painless post operative periods,will always be in demand.it is that simple an issue.
i would also remind my abps peers,that mis has too evolved.today,many mis surgeons utilize c-arms inorder to aide in the surgical visualization, as well as ultrasound sonography.
furthermore,many surgeons get pre op clearances from the patient's primary doctor,in cases of patients with remarkable medical histories.there has also been a new program which certifies an ambulatory surgeons office facility,through adherance of standard protocols.these protocols rival those currently used by plastic surgeons,i might add.
i am taking the time to learn these techniques in order to make me a more complete surgeon.if i don't as a podiatrist,the plastic surgeons will.i am already seeing it in my area.
Please note that there is a new college in the UK for MIS Training.
The College of Minimally Invasive Foot and Ankle Surgery.
Soon we will launch it openly in the UK.
i think that one of the points that is being missed in this whole debate,is an economical one.mis surgery in the right hands not only works well.it pays very well too.patients prefer it and because it is fast and doesn't require trips to the hospital it can be very profitable.quite frankly,a conventional surgical practice can't compete with a well run mis practice.it is not an opinion.it is a fact.there are surveys in medical management journals that bears this out (florida medical business,july,2003).there are very successful mis practices that have opt out of medicare and charge only cash for their procedures.there are two in my area doing very well.
with this said you have to recognize that the surgical establishment in our profession has labored long to establish an elite surgical class ,while the remainder of our graduates were left to fend for themselves as callous trimmers.the idea being that these glorified chiropodists would then send all the surgeries down their way.this is impractical,since we are considered a surgical specialty.
luckily,preceptorships and better residency educators equaled the playing field.but practitioners that were a product of this system are left in frustration.they have a psr36 and a bad case of RD itis (real doctor syndrome) and can't handle the fact that they are just d.p.m.'s like the rest of us.this is the reason that they are so vehement about squashing mis,at a time when orthopedic surgeons are lining up to learn it.
incidentally,my name is rick perez,d.p.m.,i am a buspm graduate with a psr 24 and i went to the academy of ambulatory surgery to learn how to better serve my patients.
That’s all just fine, but misses the main concern. Put patient safety before making money and you might construct a better argument.
From your response it seems you did 4 + 2 years then trained in MIS. US trained DPMs are better trained medically than UK trained Pods (at this moment in time). In the UK we are talking about 3-year trained podiatrists and formerly non-registered chiropodists going straight to MIS. From the CMIFAS website it seems you can apply for full status if you have done 8 cases.
This is a short cut to surgery when a better system has developed over the last 31 years – 5-6 years post grad at a very high level. I sympathise with the position you found yourself in but the position is very different in the UK to the one you are familiar with. I have studied many times in the US so I can speak with experience.
I do MIS techniques. They do work, but not for the majority of cases. How many orthopods train in just MIS??? None. They train for years in open surgery – THEN learn MIS techniques.
To embark upon the Fellowship programme the practitioner should have at least three years post-graduate podiatric work experience
Associate Membership
There are two routes for Associate members to progress to Full membership.
1.• Those already doing surgery have up to two years to submit eight cases of ambulatory foot surgery to the membership committee, plus must complete some compulsory training.
2.• Those Associate members who do not have formal training will have to undergo Parts 1,2 and 3 of the College’s training programme to perform MIS
The course may be completed within four years.
Full Membership
For practitioners who have the skill and proficiency in the surgery
Practitioners with advanced study may apply for exemptions and attendance at seminars with appropriate courses may be included in this. (Please send copies of your course certificates).
Speaking as a lowly Chiropodist, (Working in England!). I to like Ian above, but coming from the other end of the profession, stand aghast at the thought of an ordinary Podiatrist (Degree or otherwise?) entering into M.I.S. surgery without the training describe by Ian!
I would have thought in England an M.I.S. Surgeon (Other than from, the traditional sources of medical training!), would be swatted at birth by the Royal College of Surgeons or the B.M.A.!!!
Isn't the term 'DOCTOR OF MEDICINE' protected in English Law? Also the practice of the same defined in law. Are they not CRIMINAL OFFENCES if not practiced by medically trained doctors and surgeons??? Certainly not two or three years courses of ordinary podiatry???
i was not familiar with the differences in education between britain and te states.i can tell you that with regards to the states there is greater parity in education between guys performing mis today and conventional surgery.percutaneous podiatric surgeons in the states have the training and priviledges to do whatever surgical procedure they choose,at least forefoot that is.our residency programs are standardized,with the exception of advanced rearfoot programs.
here is the ugly truth about all this.the only complex rearfoot procedures these guys are getting are low income,indigent,managed care insurance the orthopods don't take.that is what has spawned this deep frustration.then they go out on the open market and have to compete with us glorified chiropodist and they can't take it.i know what i am telling you i used to be one of them.
as for your comment about the low qualification standards for diplomate status.let me let you in on another dirty little secret.a good portion of the old timers were all grandfathered into the abps and acfs.the oral aspect of the board certification (abps) is very politically subjective.i know i benefited greatly from it.
in the u.s.a. we podiatrist eat our young.this has nothing to do with quality patient care trust me.
i am curious about one thing tell me more about this mis school in britain.how does this work?
I get over to the States every year so I know some of your history. You have my sympathies.
The MIS group can be found at the CMIFAS website detailed above. We all know MIS procedures work – for me it is not about that. Compare that to the training scheme the Society of Ch and Pods has developed over the last few years.
If you go to the Podiatry Mailbase and search for MIS under:
ian,
thank you for the infor.incidentally,how exactly does the scope of practice with surgery work in britain.i don't understand what the difference between a traditionally trained pod and practitioners from a chiropody means.where do british pods perform surgery and how are they reimbursed (private insurance,cash,national health plan,etc).
what is this purpose of this mis college to act as a sort of postgraduate training or as an entirely new school?
by the way i perform both conventional and mis surgery.it depends on what the patient needs.
Hi Rick,
In the uk a podiatry degree is a 3 year university course, the scope of practice with this qualification extends to use of local aneasthetic, nail surgery(phenolisation mainly) palliative care, orthoses, biomechanics diabetic wound care etc. Surgical training is a post grad undertaking, after 2 years working at basic level, you can undertake surgical training, this is initially acedemically based, leading to a masters degree equivalent, practical surgical training follows successful acedemic progress, this is usually for 2-3 years (maybe 1-2 days per week in a surgical department). Following success in a practical surgery examination a candidate would be expected to spend the next 3 years working under the auspices of an established consultant podiatric surgeon, undertaking a body of work before being issued with a certificate of completion of training. At this point one would be able to head a surgical team in your own right.
there are around 60 surgical units active in the national health service currently, staff in these departments are salaried employees, in addition many consultants work privately, some pateints will be able to fund surgery from health insurance, the rest are self funding (cash)
the concern about a new player in surgical training in the uk is that such splinter groups may undo some of the hard work of the last 30 odd years. For the last 7 or 8 years we have enjoyed a united approach in surgical training and have been able to accomplish many positive things, in contrast to some of the problems our profession faced in the years before the amalgamation of the previous 2 routes to surgical practice.
... and the point that Rick does open surgery too is key - UK MIS "surgeons" will only be able to do MIS. The Podiatry Mailbase archives explanins how the situation came about...
Interesting threads, I think MIS has its place, but not really in bunion surgery where the actual ideal is realignment. We have come to far to take this step backward. I think the postings linked above to the other forum shows how our profession still lacks in unified training and podiatry ideals. Hopefully , the new residency protocol of 3 year programs in hospital settings will help to unify our profession.
I just painfully read through all the responses (MIS & Dr. Tucker ) in the Foot Health Forum. It seems that there is a great divide concerning accredidited foot surgeons and MIS surgeons. I also believe that in the States, many foot doctors left out of residency and 'formal training' resort to MIS surgery in their office. Unfortunately, I too, have seen many disasterous results concerning this type of surgery. But this is mainly out of the lack of training by the surgeon and these particular surgeons misleading the public (ie painless surgery, no scars, etc. etc.)
I am not board certified and don't really believe in its merit anyway. I think it is best that 'patients beware' when it comes to MIS in the States. I applaud the CMIFAS to take MIS a step further. I think it has its place, but from my experience, I will never perform surgery with a burr and blind ambition.
I note from the list of nominees standing for election to the Health Professions Council, a Somuz Miah as an alternate from the podiatry profession. Out of interest, are the courses proposed by CMIFAS recognised by the regulator?
Debate re minimal invasive surgery
mis surgery
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